In 1918, psychoanalysis found itself in crisis. “Therapeutic activities are not far-reaching,” Freud lamented, and “even by working very hard,” the analysts' results “are almost negligible [given] the vast amount of neurotic misery…. At present we do nothing for the wider social strata.”1 Freud's solution to this impasse was to create “institutions or outpatient clinics…[where] treatment will be free.” And in the next decade, in Vienna, Berlin, Budapest, and London, some of the movement's most interesting thinkers, like Sandor Ferenczi, Ernst Simmel, Edith Jacobson, Otto Fenichel, and Wilhelm Reich, followed Freud and indeed made psychoanalysis accessible to students, artists, craftsmen, laborers, factory workers, office clerks, unemployed people, farmers, domestic servants, and public school teachers.
By 1924, public interest in psychoanalysis “actually moved faster than…the medical profession,” Paul Federn wrote, and the Viennese demanded psychoanalytic information, referrals, and advice from their doctors in virtually all areas of specialization.2 Psychoanalysis even found its way into the tabloids of the day. “Lonesome: You are 29-years-old, intelligent, educated, with a good job and you long for a companion who would share with you sorrow and joy…. This is no doubt a case which necessitates psychoanalytic treatment. Consult with the Psychoanalytic Ambulatorium, Vienna, Ninth District, 18 Pelikangasse, Office hours from 6 to 7 p.m.,” answered the magazine columnist from Bettauer's Wochenschrift.3
Nearly a century later, “neurotic misery” remains widespread, clinicians and consumers are peeved, and at one time or another, the professional journals speak to the decline in psychoanalytic practice or issue a postmortem for the profession. The number of free-standing outpatient mental health clinics decreased dramatically in the last decades of the 20th century, from 51.4 percent of all outpatient services in 1970 to 25.3 percent in 1988.4 Moreover, the press for affordability has become an increasingly dominant controversy within the clinics, institutes, and other organized providers of mental health services today. In other words, the moment bodes well for psychoanalysis to re-examine how the profession re-invented itself 90 years ago.
This re-invention may already be underway. Since 1998, the Association has encouraged the efforts of community-based programs around the country, and most institutes (as well as private practitioners) maintain a range of low-cost services. To support these endeavors, however, analysts must wrangle with the issue posed in 1925 by the German psychoanalyst Max Eitingon: For a clinic to be successful, as Eitingon explained in his annual report on the Berlin Poliklinik (the Berlin Society's free clinic), the analysts should agree that “the factor of the patients paying or not paying has no influence on the course of the analysis.”5 Eitingon's line of reasoning followed Freud's own social democratic idea, “that the poorest man should have just as much right to assistance for his mind as he now has to lifesaving help offered by surgery,” and that the fee—or lack thereof—was as much the clinician's issue as the patient's.
Unlike today's low-cost clinics, the Poliklinik and the Vienna Ambulatorium (the cooperative clinic associated with the Vienna Psychoanalytic Society), were free clinics literally and metaphorically: They freed people of their neuroses and, like the municipal schools and universities of Europe, they were free of charge. In the heady climate of progressivism and social movement between the two world wars, psychoanalysis was believed to share in the transformation of civil society and the new outpatient treatment centers were to help restore people to their inherently self-regulating and productive selves.
Elizabeth Ann Danto, Ph.D., is associate professor of social work at Hunter College–City University of New York. She is the author of Freud's Free Clinics—Psychoanalysis & Social Justice, 1918-1938, published by Columbia University Press in May 2005.
Like all free clinics historically, these had the role of providing mental health care to poor people, the socially disenfranchised, and those who sought help through untraditional channels. Of course, as Anna Freud said in 1968, the psychoanalysts too were viewed as untraditional, as “pioneers, not only because they broke new ground, but also in the sense that their endeavors ran counter to and ignored the conventional restrictions of their time.”6 Most of the analysts never even considered weighing the effectiveness of treatment against the financial burden imposed on the patient. What's more, they assumed a specific obligation to donate a portion of their time to people who could not otherwise afford treatment.
The free clinics changed the way analysts reached all social classes without changing the therapeutic process. Their funding strategies were interesting. For one, the systematic distribution of Erlagscheine, or vouchers, to current or prospective patients (who would later use the voucher as a form of currency to pay another doctor) made for an especially versatile type of personal check. Within a medical community like a hospital, an authorized signer could use the voucher to personally reimburse a colleague who had donated time to treat a patient. In private practice, a physician could endorse an Erlagschein to a clinic like the Ambulatorium, as a monthly financial contribution, substituting the donation for treatment hours they would ordinarily provide in person. Freud, arguably the original private practitioner of psychoanalysis, regularly wrote out monthly Erlagscheine of 200 to 400 schillings (roughly $50 to $100) for the clinic. Of course, some patients did pay according to a sliding scale of fees. But relying on patient fees was both risky and ideologically counterproductive, and it made little sense in a post-war economy of high unemployment and inflation.
The governing Social Democrats kept wages deliberately low, and instead used local taxes to build up a large scale public health, welfare, sanitation, and housing infrastructure. Unlike individual wages, these centrally planned projects effectively redistributed taxes toward those most in need. Along the same lines, the psychoanalysts (at least two of whom, Josef Friedjung and Paul Federn, were City Council members) formulated the “one-fifth” formula whereby, of every five patients, one would be treated gratis. Psychoanalytic society members who decided not to treat patients free of charge according to the “one-fifth” rule, contributed instead to the salaries of a growing number of paid assistants and interns at the clinics: In 1924, all Society members in Berlin and Vienna allocated an additional 4 percent of their membership fees to support the clinics.7 This revenue, along with occasional cash infusions from Max Eitingon in Berlin, and later Pryns Hopkins in London and Marie Bonaparte in Paris (in addition to some Americans) pretty much sustained the clinics.
The free clinics changed the way analysts reached all social classes without changing the therapeutic process.
The rise of free clinics, then, allowed psychoanalysts to be consistent with the prevailing Social Democratic model and, at the same time, to increase the visibility of their new profession in almost all major cities in Europe. “In the long run the success of a clinic would mean a general encouragement of psychoanalysis,” Freud's translator and friend, James Strachey, wrote from London to his wife Alix, then living in Berlin, “and would eventually benefit us personally.”8 The Vienna Ambulatorium provided a perfect case in point. The free clinic did not seek out a mainstream patient base and was sustained relatively cheaply. Inside the cramped medical offices that the Ambulatorium shared with a hospital's cardiology unit, the analytic couch was a metal examination table with a thin springless mattress.
Dozens of people a day streamed through the doors at 18 Pelikangasse without distinction of illness or social class, heart patients in the morning mingling with analytic patients in the afternoon and evening. The clinic did so well that Eduard Hitschmann, the director, complained in 1932 of its overuse by schools and clubs, teachers, school doctors, and personal pediatricians who referred children “from all strata of the necessitous classes.”9 It did even better with adult men who outnumbered female patients in most years by at least 50 percent; to go by Hitschmann's data, “impotence” ranked as the clinic's most frequently recorded diagnosis, reiterating how psychoanalysis would give men—who already had more social freedom than women—license to address sexual dysfunction and, coincidentally, produce families and rebuild a vigorous state. Not that women were ignored. It was one of the accomplishments of psychoanalysis to assert that women did have sexuality, but saying that women of the “lower” classes had sexual autonomy was even more daring.
In Berlin, itself a great center of urban daring in the 1920s, Max Eitingon ran the Poliklinik with clinical judgments that could seem idiosyncratic today, and he tended to challenge the analysts on their views of treatment and social class. Psychoanalysts like Otto Fenichel and Ernst Simmel, who were gratified by his wholesale trust in patients' honesty (that they “pay as much or as little as they can or think they can”),10 also applauded his fondness for collecting data (“statistics…[are] the test of our courage”). They liked to try out his variations on treatment (“to systematically and in every case reduce the length of the analytic sitting from one hour to half-an-hour,” for example) and experimented with time limits, crisis intervention, “fractionary” or “interrupted” schedules, and active therapies presumably influenced by Ferenczi. Eitingon seized on and supported Freud's call for free clinics early, precisely because he found that, “in private practice [these experiments] could never be undertaken.” Freud's own promotion of Eitingon and the Poliklinik's mission was only the beginning and he worried that the analysts' enthusiasm might diminish. In a 1935 epilogue to his brief bittersweet autobiography, Freud added, “Out of their own funds, local societies support…outpatient clinics in which experienced analysts as well as students give free treatment to patients of limited means.”11
London was a latecomer to the free clinics , and it was relatively heterogeneous. But local psychoanalysts saw this as a benefit in a heavily principled society like the British Psychoanalytic under Ernest Jones, and maybe this is why the London Clinic for Psychoanalysis still survives today. Since the early 1920s, the British analysts had visited foreign clinics and also invited Berliners like Melanie Klein to join up. By 1926, the British Society's goal was to build a clinic quickly, learning from Berlin and Vienna while managing their own approach to cases and research. Analysts like Sylvia Payne and Edward Glover, and especially Barbara Low, stayed close to their IPA partners, maintaining the clinics' child and adult programs. All staff treated one patient daily at the Gloucester Place facility or, as in the other societies, provided an alternative but equivalent amount of service or money to the institute.12 Freud was delighted. “Although absent from the opening of the Clinic tomorrow,” Freud wrote to Jones, referring to the clinic's ribbon-cutting ceremony, “I am all with you and feel the importance of the day.”13
Erik Erikson, Erich Fromm, Karen Horney, Bruno Bettelheim, Alfred Adler, Otto Fenichel, Melanie Klein, Anna Freud, Wilhelm Reich, Helene Deutsch, Grete and Eduard Bibring, Paul Schilder, Frieda Fromm-Reichmann—these were just some of the free clinic analysts who later fanned out across the Western world, some carrying the torch of progressivism and others concealing it. Today they are known for their theoretical revisionism and for the many ways in which they followed, transformed, or broke away from classical Freudian theory. But in the 1920s and early 1930s, the same analysts saw themselves as brokers of social change for whom psychoanalysis was a social mission, a challenge to conventional political traditions. They were a spirited group who found no antagonism between the macropolicy and microclinical levels (a conflict that characterizes and confuses practice all too often today). Not surprisingly, the ideology and organization of their free clinics echoed the era's own modernist ideology—women's right to vote, the focus on child health and welfare, the vast re-housing projects—in postwar Austria and Germany. Just as significant, the psychoanalysts' priorities, their concern for the relationship between social infrastructure and personal psychology, magnified their accomplishment. In the 1920s, psychoanalysis was as progressive a sociocultural movement as the art, music, and architecture of the era. Freud's own interest, his appreciative insistence on being included in the free clinics, has to be understood within that historical context but also applied right now.
In the 1920s, psychoanalysis was as progressive a sociocultural movement as the art, music, and architecture of the era. Freud's own interest, his appreciative insistence on being included in the free clinics, has to be understood within that historical context but also applied right now.
Eighty-five years after the 1920 opening of the Berlin Poliklinik, contemporary psychoanalysts consistently confront the bewildering cost of treatment and the divide between public and private services so often based on education and class. As we now know, this is not a new confrontation. Looking back to the Berlin and Vienna models, we can begin to reclaim the psychoanalysts' urban, clinical, and social justice legacy. “The replacement of the power of the individual by the power of a community constitutes the decisive step of civilization,” Freud wrote in 1930, and I propose to take Freud at his word.14
(1918). “Lines of advance in psychoanalytic psychotherapy.” Standard Edition 17: 166.
(1972). “Thirty-Five Years with Freud—in Honour of the Hundredth Anniversary of Paul Federn, MD.” Journal of the History of the Behavioral Sciences, 8 (1972): 38.
(1995). “Hugo Bettauer and the Political Culture of the First Republic.” Contemporary Austrian Studies, 3 (1995): 143-145.
and , eds. (1992), Mental Health, United States 1992, Center for Mental Health Services and National Institute of Mental Health, DHHS Pub. No. (SMA) 92-1942, Washington D.C.: Superintendent of Documents, U.S. Government Printing Office.
(1926). “Report on the Berlin Psycho-Analytical Institute,” May 1924-August 1925. International Journal of Psycho-Analysis 7: 139-141.
(1968). “Address to the New York Psychoanalytic Association.” In Coles, R. Anna Freud: The Dream of Psychoanalysis, Addison-Wesley Publishing Co, 1991.
(1978). “Discussions on Therapeutic Technique in the Vienna Psycho-Analytic Society (1923-1924).” Sigmund Freud House Bulletin, 2/2 30.
James to Alix Strachey. “Saturday afternoon. Jan. 24th” [192] in and , eds. Bloomsbury/Freud, The Letters of James and Alix Strachey 1924-1925, New York: W.W. Norton, 1990, 187.
(1932). “A Ten Years' Report of the Vienna Psycho-Analytic Clinic.” International Journal of Psychoanalysis, 13: 245-255.
(1923). “Report of the Berlin Psycho-Analytical Policlinic,” March 1920-June 1922. International Journal of Psycho-Analysis 4: 254-269.
(1935). “An Autobiographical Study.” Standard Edition 20: 71.
“Report of the British Psychoanalytic Society,” Fourth quarter 1929. International Journal of Psychoanalysis 11 (1930): 119; also “Minutes of October 2, 1929 of the Board of the British Psycho-Analytic Society,” Archives of the British Psychoanalytical Society, by permission.
“Letter to Ernest Jones 27 September.” 491 (1929). In , The Complete Correspondence of Sigmund Freud and Ernest Jones, 1908-1939. Cambridge: Harvard University Press, 1995.
(1930). “Civilization and Its Discontents.” Standard Edition 21: 134.